Provider Demographics
NPI:1073567251
Name:ADELEYE, OLUFEMI (MD)
Entity Type:Individual
Prefix:
First Name:OLUFEMI
Middle Name:
Last Name:ADELEYE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 366
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-0005
Mailing Address - Country:US
Mailing Address - Phone:901-681-9895
Mailing Address - Fax:
Practice Address - Street 1:1890 GOODMAN RD E
Practice Address - Street 2:SUITE 101
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9504
Practice Address - Country:US
Practice Address - Phone:662-536-1892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18315207PE0004X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06180721Medicaid
F47915Medicare UPIN
MS06180721Medicaid
TN3808148Medicare PIN